Comparison of clinical characteristics in obsessive-compulsive disorder and body dysmorphic disorder

Journal of Anxiety Disorders, Vol. 11, No. 4, pp. 447-454, 1997 Copyright Q 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0887.6185/97 $17.00 + .OO

Pergamon

PII SO887-6185(97)00020-O

Comparison of Clinical Characteristics in Obsessive-Compulsive Disorder and Body Dysmorphic Disorder DEAN

MCKAY, PH.D., FUGEN AND JOSE

Institute

A.

NEZIROGLU, PH.D., YARYURA-TOBIAS, M.D.

for Bio-Behavioral

Therapy

and Research

Abstract-Recent

research has suggested that body dysmorphic disorder (BDD) is part of the spectrum of obsessive-compulsive disorders. In order to determine the extent of similarity for psychopathology measures, patients diagnosed with BDD were compared to a group of patients diagnosed with obsessive-compulsive disorder (OCD) on obsessionality, compulsivity, overvalued ideas, depression, and anxiety. Results indicate that BDD patients are similar to OCD patients for measures of obsessionality and compulsivity when BDD symptoms are assessed as such. BDD and OCD patients were also similar for measures of depression, and state and trait anxiety. OCD patients had higher levels of anxiety when measuring common physical symptoms associated with this affective reaction. BDD patients had higher levels of overvalued ideas, but fewer obsessive and compulsive symptoms. Overall, the results suggest that BDD is a variant of OCD, with special considerations given to degree of belief conviction (overvalued ideas). 0 1997 Elsevier Science Ltd

Recent literature has suggestedthat obsessive-compulsivedisorder (OCD) and body dysmorphic disorder (BDD) shareimportant clinical characteristics and lend justification to the formulation of a spectrumof obsessive-compulsive disorders. BDD is characterized by excessive concern with perceived bodily defect, and may only be considered BDD when it is not related to an eating disorder such as anorexia or bulimia (Diagnostic and Statistical Manual of Mental Disorders DSM-IV, American Psychiatric Association, 1994). Portions of this data were presented at the 27th annual meeting of of Behavior Therapy. Atlanta, GA. Requests for reprints should be sent to Dean McKay, who Department of Psychology, 113 West 60th Street, New York, NY, Bio-Behavioral Therapy and Research, 935 Northern Boulevard, 0 1997 Elsevier Science Ltd. All rights reserved.

the Association

for Advancement

is now at Fordham University, or Fugen Neziroglu, Institute for Great Neck, NY 11021.

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ET AL.

Most of the literature linking BDD to OCD has been theoretical in nature, with limited empirical support. For example, Hollander, Cohen, and Simeon (1993) report that of 50 patients diagnosed with BDD, 39 had clinically significant symptoms of OCD as well. However, of this group, large percentagesalso had depression(n = 34) and other anxiety disorders(n = 30). Recent epidemiology researchshows that BDD has a comorbidity of OCD (Simeon, Hollander, Stein, Cohen, & Aronowitz, 1995). Other studiessupport the inclusion of BDD as a member of the spectrum of OCD by virtue of the similarity of response to medications typically used for OCD (Hollander, Liebowitz, Winchel, Klumker, & Klein, 1989; Neziroglu & Yaryura-Tobias, 1993a).Other support for its inclusion in the spectrum of obsessive-compulsivedisorders comes from the response to behavioral treatments, such as exposure with responseprevention, which is popular for usewith OCD (Neziroglu & YaryuraTobias, 1993b; Rosen, Reiter, & Orosan, 1995). The recent revision of the DSM-IV has accommodatedthe theoretical conceptualizations regarding the obsessive-compulsivespectrum by including an optional identifier for disorders included in this category. Specifically, an additional notation of “with poor insight” may be addedfor diagnosesof OCD, BDD, and other disorders considered to fall in the spectrum of OCD (an additional diagnosis where this is relevant, for example, is hypochondriasis). This is an effort to include additional theoretical work suggestingthat OCD may occasionally presentwith elevated levels of “overvalued ideas” (Kozak & Foa, 1994). Overvalued ideation occurs when patientswith OCD (or other identified spectrum disorders) no longer view their symptoms as senseless,but lack adequateconviction to consider them as having a delusion. Overvalued ideas have been identified as predictive of improvement in OCD (Foa, 1979) and observed as a feature of BDD (Neziroglu & Yaryura-Tobias, 1993a). Other researchhas found that BDD is likely to presentwith a number of personality disorders (Neziroglu, Stevens, McKay, Todaro, & Yaryura-Tobias, 1996) and remain symptomatic for depressionfollowing trials of treatment and maintenance with behavior therapy (McKay et al., 1997; McKay, in press). The presentinvestigation is intended to shedadditional light on the ways in which OCD and BDD are similar on a variety of dimensionsof psychopathology. Basedon the conceptualizationsof BDD to date, it is hypothesized that this patient group would exhibit greater levels of depression (Hollander et al., 1993), stronger conviction of belief in the rationality of pathology (overvalued ideation; Neziroglu & Yaryura-Tobias, 1993a; McElroy, Phillips, Keck, Hudson, & Harrison, 1993), and similar levels of obsessive-compulsivesymptoms unrelated to BDD (Hollander et al., 1993; Simeon, Hollander, Stein, Cohen, & Aronowitz, 1995).

OCD

AND

BDD

449

METHOD Subjects Both groups of patients were seen at an outpatient facility (Institute for Bio-Behavioral Therapy and Research) specializing in the treatment of anxiety disorders and OCD. They were referred from a variety of sources, such as psychologists and psychiatrists in the community, other patients, and advertisements in local media or by attending community self-help groups. The composition of the diagnostic groups were as follows: Obsessive-compulsive disorder sample. The sample of patients comprising the OCD group totaled 22. There were 13 males and 9 females. The mean age at time of testing was 33.4 years (SD = 7.8). The mean age of onset for OCD was 17.3 years (SD = 6.8). Body dysmorphic disorder sample. The sample of patients comprising the BDD group totaled 23. There were 7 males and 15 females. The mean age at time of testing was 26.4 years (SD = 4.3). The mean age of BDD onset was 17.1 years (SD = 6.8). Diagnostic criteria. Diagnoses were established using the Structured Clinical Interview for DSM-III-R (SCID-P; Spitzer, William, Gibbon, & First, 1992). The SCID-P has been found to have adequate reliability for diagnosing the range of Axis I psychopathology enumerated in the diagnostic manual (Segal, Hersen, & Van Hasselt, 1994). At the time the data was collected, the version for DSM-N was not yet available. Further, reliability data from diagnoses were not available on this sample. However, five patients from each group were evaluated with the SCID-P independently, with high agreement between raters (both kappas = 1.0). Materials Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989). The Y-BOCS is a lo-item clinician administered scale that assesses obsessions and compulsions, as well as forming a total score. There are five identical items for each subscale, assessing frequency, distress, social/occupational interference, resistance, and control over either obsessions or compulsions. Each item is rated from 0 to 4, with higher scores indicative of greater symptomatology. Recent factor analytic findings suggest that this scale is composed of two scales (obsessions, compulsions) and the data are presented in that fashion (McKay, Danyko, Neziroglu, & Yaryura-Tobias, 1995). Yale-Brown Obsessive-Compulsive Scale for Body Dysmorphic Disorder (YBOCSBDD). This scale is identical in form to the original Y-BOCS, except each

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item was tailored to assess symptoms of BDD, and has been used elsewhere (Neziroglu et al., 1996) and has been reported to have adequate reliability (K. Phillips, personal communication, June 5, 1995). For the purposes of comparison, the Y-BOCSBDD was scored the same as the Y-BOCS (subscales for obsessions and compulsions). Overvalued Ideas Scale (OVIS; Neziroglu et al., 1996). The OVIS is a scale designed to assess overvalued ideation in obsessive-compulsive patients. It is composed of three related scales, which are based on primary beliefs associated with psychopathology, and is clinician administered. It is a flexible scale that yields a ratio based on the number of beliefs central to pathology and the number of items. Total scores range from 0 (no overvalued ideas) to 10 (extreme overvalued ideas). It has been found to have adequate reliability and convergent validity (Neziroglu et al., 1996). Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) The BDI (Beck et al., 1961) was administered to assess signs and symptoms associated with depression. Composed of 21 items, it has been well established as having adequate reliability and validity. Each item is rated from 0 (neutral) to 3 (severe symptomatology). Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steec 1988) The BAI (Beck et al., 1988) was administered to assess symptoms of anxiety typically experienced by each patient group. Each item is rated in a similar fashion to the BDI, and assesses symptoms and cognitions associated with anxiety symptoms. Its reliability and validity have been found to be adequate. State Trait Anxiety Inventory (STAI; Spielbergel; 1983). The STAI (Spielberger, 1983) is composed of two subscales (state and trait anxiety) and was administered to al&m any findings associated with the BAI and to determine the nature of long-standing anxiety symptoms of each patient group. Each scale is composed of 20 items, with items rated from 1 to 4 (1 = not at all; 4 = very much). It is a norm referenced test, with adequate reliability and validity. Procedure Once diagnoses were established with the SCID-P, patients were interviewed with the Y-BOCS, Y-BOCSBDD (for BDD patients), and the OVI. They were then administered the self-report materials, which were completed in the office before leaving.

RESULTS The results are organized based on areas assessed, such as affective state (BDI, BAI, STAI) or features of obsessive-compulsive symptomatology (Y-

OCD

MEANS

AND STANDARD

451

AND BDD

TABLE 1 FOR MEASURES FOR BODY DYSMOWHIC OBSESSIVE-C• MPULSWE DISORDER SAMPLES DEVLQIONS

Measure Y-BOCS: obsessions Y-BOCS: compulsions Y-BOCSBDD: obsessions Y-BOCSBDD: compulsions OVIS BDI B,4I STAI: statea STAI: trait”

DISORDER AND

BDD

OCD

11.0 (2.2) 8.8 (2.9) 13.2 (3.1) 11.5 (3.9) 1.6 (0.5) 21.6 (6.1) 16.9 (7.1) 54.7 (9.8) 58.6(10.1)

16.2(3.4) 12.4(5.7)

3.8(1.3) 16.4(5.2) 24.1(8.1) 51.3(7.4) 55.7(9.3)

“Converted from raw scores to T scores. Standard deviations are in parentheses No&. Y-BOCS = Yale-Brown Obsessive-Compulsive Scale; Y-BOCSBDD = Yale-Brown Obsessive-Compulsive Scale for Body Dysmorphic Disorder; OVIS = Overvalued Ideation Scale; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; STAI = State Trait Anxiety Inventory.

BOCS, Y-BOCSBDD, OVIS). The Dunn-Bonferroni correction was utilized to control for type I error when multiple comparisonswere made with a single measure. Obsessive-CompulsiveSymptomatology The results indicate that there were no differences between the level of symptomatology of BDD patients compared to OCD patients, when both pathologies were assessedas obsessionalor compulsive (obsessionsor compulsion subscale of Y-BOCSBDD compared to corresponding subscale of Y-BOCS; ts cl). However, BDD patients had significantly lower levels of obsessionalitycompared to OCD patients (Y-BOCS obsessionsubscale,tc4, = 4.13, p < .Ol) and lower levels of compulsivity (Y-BOCS compulsion subscale, tea, = 3.91, p < .OOl). When overvalued ideation was assessed with the OVIS, BDD patients scored significantly higher than OCD patients (tcd4)= 3.89, p < .Ol). Affective Measures Depressive and anxious affect was assessedwith the BDI, BAI, and STAI. Analyses indicate that there was no significant difference for depression,or state or trait anxiety (All ts < 1.2). However, there was a significant difference for the BAI, with OCD patients scoring higher than BDD patients (tcs5)= 6.22, p < .OOl). All data for measuresare presentedin Table 1.

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DISCUSSION The present study was an investigation into the extent to which BDD and OCD are similar psychopathological entities. Since little empirical data has accumulated documenting similarities in primary psychopathology, and because BDD has been considered a part of the spectrum of obsessive-compulsive disorders, this investigation was warranted. The findings from this preliminary study indicate that BDD may be a more severe variant of OCD. This is based on the following findings: BDD patients had considerably stronger conviction of beliefs (as assessed with the OVIS), were equivalent in measures of BDD psychopathology when conceptualized as obsessional or compulsive in nature; and although not statistically significant, showed clinically elevated levels of obsessive-compulsive behavior not related to BDD. A case could be made that in the aggregate, BDD patients experience more severe obsessional and compulsive symptoms than OCD patients. Further, on other measures of psychopathology (BDI, STAI), these groups were statistically equivalent. The results here could be considered mixed, since there was a significant difference between the groups when anxiety was assessed with the BAI, with OCD patients scoring significantly higher. It could be explained based on the differences in measures. The BAI assesses primary physical symptoms associated with anxiety, whereas the STAI measures cognitive symptomatology and styles of responding associated with anxious states. Future research should clarify the role anxiety plays in BDD, since the results here are not clear. Of importance in this study is the finding that BDD patients experienced considerably higher levels of overvalued ideas. The issue that now remains is the extent to which BDD may be a delusional disorder, rather than a variant of OCD. This has been considered previously (McElroy et al., 1993) and the conclusion was that patients with BDD who also suffered from psychosis differed from other BDD patients only on psychotic dimensions, and not on BDD dimensions. This means that the experience of BDD was not unlike OCD, even when psychosis was present. However, more research is required to examine the role of overvalued ideas, relative to delusions or other thought disorders, in BDD. In addition, somatosensory changes may be present in BDD. Actual perceptual changes may account for the misperception of defects similar to other forms of dysperception noted in OCD (Yaryura-Tobias & Neziroglu, 1983, 1996). Although this study did not include perception as a variable in comparing the two disorders, it is suggested for future research. Contrary to predictions, BDD patients were not statistically significantly higher on the measure of depression. This lends additional credence to the notion that BDD is a variant of OCD. However, this assessment is not without its limitations. Specifically, since there were potential measurement issues in the assessment of anxiety states, and only one measure of depression was used, it

OCD

AND

BDD

453

is reasonable to suggest that a different outcome may be obtained for a different measure of depression. It has been reported that during exposure therapy, BDD patients often respond with depressive symptoms (e.g., crying, negative statements about themselves) while OCD patients are more likely to demonstrate symptoms of anxiety (Neziroglu & Yaryura-Tobias, 1996). Another important issue to consider in the assessment of BDD symptomatology lies in the measurement of symptoms as obsessions or compulsions. It is possible that the measurement of obsessions or compulsions requires a different scale of measurement relative to the types of activities assessed. For example, assume that frequency of ritual is being assessed with the Y-BOCSBDD. If the compulsion is visits to the dermatologist, and this activity occurs twice a week, it would be rated low because frequency is measured in absolute terms. Instead, a normative value for comparison may be a more appropriate manner of assessing these behaviors. Some limitations of the present investigation are as follows. First, although BDD has been conceptualized as a variant of OCD, the evaluation was designed to measure BDD as such. Specifically, the measure of obsessive-compulsive symptomatology (Y-BOCS) was modified for BDD, explicitly suggesting the BDD is a member of the spectrum of OCD without direct empirical testing. Future research should endeavor to develop reliable and valid measures of BDD that do not necessarily cast the condition in an OCD framework. Following this, efforts to directly compare the conditions may be more satisfactorily completed. Second, measures of behavioral avoidance would be useful for fully comparing the two groups, especially since other empirical evaluations have found that individuals with BDD engage in considerable avoidance (McKay, in press; McKay et al., 1997). In summary, it appears that BDD shares several important aspects of psychopathology, including obsessionality and compulsivity specific to BDD concerns, depression, and certain aspects of anxiety symptomatology. Further, as a variant of OCD, BDD may be considered more severe in its manifestation, evidenced by its significantly higher levels of overvalued ideas. Future research is required to determine the extent to which BDD is actually a part of the spectrum of OCD, or part of the spectrum of thought and/or perceptual di sorders .

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